Pellagra secondary to selective eating in a child with autism.

Once a significant cause of morbidity and mortality, health care providers rarely see primary pellagra in developed countries where fortification of foods with niacin is commonplace and niacin-rich foods are generally widely available. We report a ten-year-old boy with autism spectrum disorder who presented with photosensitive dermatitis which resolved after vitamin supplementation and dietary changes. In this child, the pellagra developed as the result of a long-term pattern of selective eating. Restricted diets, even to the point of nutrient deficiencies, are well-documented among children with autism spectrum disorders (ASD).

Sensory Eating Problems Scale (SEPS) for children: Psychometrics and associations with mealtime problems behaviors.

The present study developed the 22-item Sensory Eating Problems Scale (SEPS) to measure sensory aspects for children surrounding eating, documented psychometrics of SEPS subscales, and examined their association with mealtime behavior problems. Study participants were 449 caretakers of children referred to feeding clinics, including children in three special needs status groups: autism spectrum disorder (ASD), other special needs, and no special needs. Caretakers completed surveys to report children's demographics, four measures of children's mealtime behavior problems, and five-point ratings for how often children showed various sensory feeding reactions. Exploratory factor analysis of the sensory feeding items identified six SEPS subscales with acceptable goodness-of-fit, internal reliability, and test-retest reliability: Food Touch Aversion, Single Food Focus, Gagging, Temperature Sensitivity, Expulsion, and Overstuffing. ANCOVAs revealed that child demographics most associated with higher SEPS subscale scores were younger age and special needs. Multiple regression analyses found that children's mealtime behavior problems were most often associated with SEPS subscales of Food Touch Aversion, Single Food Focus, Expulsion, and Overstuffing, with the set of six subscales explaining 18-44% of variance in mealtime behavior problems. Suggestions for how clinicians and researchers may find the SEPS useful for assessment and intervention are provided.

The Parent Mealtime Action Scale revised (PMAS-R): Psychometric characteristics and associations with variables of clinical interest.

The purpose of the present study was to provide a revised and more psychometrically-examined version of the Parent Mealtime Action Scale (PMAS-R), then to examine how well the PMAS-R subscales explained variance for four variables relevant in clinical settings. Study participants included 238 parents of children referred to a hospital-based feeding program (72.3% male children; mean age = 72.2 months; 80 with autism spectrum disorder, 77 with other special needs, 81 with no special needs). Parents completed questionnaires to report child demographics and diet habits. Parents also used a five-point rating instead of the original three-point rating to report their usage of the 31 PMAS feeding practices. Using five-point ratings, the nine subscales of the PMAS-R demonstrated improved internal reliability and test-retest reliability compared to those published for the original PMAS. ANCOVA indicated that special needs status was the child demographic variable most associated with PMAS-R feeding practices. Hierarchical multiple regression revealed that after controlling for child demographics, the nine PMAS-R subscales explained 26-49% of the variance for four variables of clinical interest (fruit and vegetable consumption, snack consumption, total food variety, and weight status). These variables of clinical interest were most often associated with "permissive" feeding practices including low Daily Fruit and Vegetable (FV) Availability, rarely using Insistence on Eating during meals, often using Many Food Choices, and often using Child-Selected Meals. The present study provides a more psychometrically-sound measure of child feeding practices, documents the association between "permissive feeding" and variables of clinical interest, and identifies specific parent practices included in "permissive feeding".

Parent Attribution for Child Eating Scale (PACES). Psychometric characteristics and associations with child and parent variables.

Parent participation in interventions for their children's feeding problems may depend on parent attributions for the origins of these problems, but no measure is available to identify these parent perceptions. The purpose of the present paper was to develop a new Parent Attribution for Child Eating Scale (PACES), then to examine how parent perceptions measured by the PACES were associated with child variables and parent feeding practices. Participants included parents of 393 children from a hospital feeding clinic (68.2% boys; mean age = 55.4 months). Parents completed surveys to report children's demographic, medical, and feeding variables, three-point ratings for possible origins of these feeding problems, and their own use of nine child-feeding practices. Exploratory factor analysis of the parent ratings produced the 21-item PACES with four dimensions: Permissive Parenting, Medical Treatments, Oral Problems, and Vomiting Fear. The PACES showed acceptable goodness-of-fit, internal reliability, test-retest reliability, and support for its validity with expected correlations with child and parent variables. Multiple regression revealed that nine child variables (age, body mass index, gender, autism, gastrointestinal problems, neurological problems, oral motor problems, texture feeding problems, diet variety) explained 19-41% of the variance in the four PACES attributions, with oral motor problems significantly correlated with all of them (negatively with Permissive Parenting, positively with the other three), suggesting that its occurrence in combination with other child variables guides parent explanations for children's feeding problems. Multiple regression also found that Many Food Choices was the only parent feeding practice significantly correlated with all four PACES attributions (positively with Permissive Parenting, negatively with the other three), suggesting that it may be parents' primary response to attributions they develop for their children's feeding problems.

Nutritional Status and Feeding Behavior of Children with Autism Spectrum Disorder in the Middle East and North Africa Region: A Systematic Review.

Autism spectrum disorder (ASD) in children is associated with increased risks of overweight/obesity and underweight, altered nutrient profile, and abnormal feeding behaviors. This systematic review aimed to elucidate the literature on the nutritional status of children with ASD in the Middle East North Africa (MENA) region, by providing a summary and assessment of the body of evidence. A systematic review of English and Arabic publications up to November 2020 was conducted of five databases in addition to the grey literature, which include a nutrition-related parameter, from both experimental and observational study designs. Children with ASD (ASD-C) between 2 and 19 years in the MENA Region were the target population. For risk of bias, the Academy of Nutrition and Dietetics' Quality Criteria Checklist (QCC) was adopted. The number of published articles was grossly limited. Forty-three articles were included, of which only four articles reported a low risk of bias; therefore, the results were interpreted in light of methodological limitations. Both overweight and underweight were common in ASD-C, although not consistently different than typically developing children. Nutrient inadequacies of energy, protein, omega-3, and others; deficiencies in serum iron indicators and calcium, as well as vitamins B12, B9, and D levels; and higher levels of homocysteine and omega-6/omega-3 ratios were reported. Feeding behavior problems were also common in ASD-C. Understanding nutritional requirements and food preferences can guide the planning of the appropriate comprehensive interventions for ASD-C. Various nutritional and behavioral concerns were identified in the included studies; however, they were subject to methodological weaknesses, which limited the generalizability of these results. Future research is warranted that must be directed to finding strong evidence using robust study designs on nutritional status and feeding behaviors of ASD-C, with a particular emphasis on the MENA Region.

Mother's feeding practices for children 3-10 years of age and their associations with child demographics.

The present study examined relationships between mothers' feeding practices and child demographics such as gender, age, weight status, and family income. This cross-sectional analysis was conducted using data from 2259 children between 3 and 10 years of age who were sampled for the development of the Parent Mealtime Action Scale. No child gender differences were found in mothers' feeding practices. Older children received more Fat Reduction and Many Food Choices, but less Positive Persuasion, Use of Rewards, Insistence on Eating, and Special Meals, with differences in these feeding practices being most notable from before to after school age. Overweight children received less Insistence on Eating and more Fat Reduction than underweight or normal weight children. Children with the lowest family incomes received less Fat Reduction, less Daily FV Availability, more Use of Rewards. Results suggest that mothers respond to changing conditions, possibly including feedback from school nurses, increases in children's weight status, and availability of financial resources.

Kid's Choice Program improves weight management behaviors and weight status in school children.

The present study examined the effectiveness of the Kid's Choice Program (KCP) for increasing children's weight management behaviors, and decreasing body mass index percentile (BMI%) for overweight and average-weight children. It also evaluated KCP characteristics relevant to long-term application in schools. Participants included 382 children assigned to two groups: a KCP group that received token rewards for three "Good Health Behaviors" including eating fruits or vegetables first at meals (FVFIRST), choosing low-fat and low-sugar healthy drinks (HDRINK), and showing 5000 exercise steps recorded on pedometers (EXERCISE), or a control group that received token rewards for three "Good Citizenship Behaviors." School lunch observations and pedometer records were completed for one month under baseline and three months under reward conditions. The school nurse calculated children's BMI% one year before baseline, at baseline, at the end of KCP application, and six months later. The KCP increased FVFIRST, HDRINK, and EXERCISE from baseline through reward conditions, with ANCOVAs demonstrating that these increases were associated with both the offer of reward and nearby peer models. Overweight (n=112) and average-weight (n=200) children showed drops in BMI% after the three-month KCP, but overweight children re-gained weight six months later, suggesting the need for more ongoing KCP application. HDRINK choice was the behavior most associated with BMI% drops for overweight children. Small teams of parent volunteers effectively delivered the KCP, and school staff endorsed parent volunteers as the best personnel to deliver the KCP, which costs approximately two U.S. dollars per child per month of application.

Validation of the parent mealtime action scale (PMAS) when applied to children referred to a hospital-based feeding clinic.

The purpose of this study was to validate the Parent Mealtime Action Scale (PMAS) when applied to a clinical sample of 231 children with feeding problems and then to examine its association with demographic variables, diet, and weight. Parents completed questionnaires that included the PMAS, the Child Eating Behavior Questionnaire, and measure of diet variety. Confirmatory factor analysis revealed good fit for the nine dimensions of parent mealtime action found in the original PMAS study. Results from the present study suggest that the PMAS provides a valid tool for measuring parent mealtime actions of hospital samples of children with feeding problems.

Parent mealtime actions that mediate associations between children's fussy-eating and their weight and diet.

The present study evaluated parent mealtime actions that mediate associations between children's fussy-eating and their weight and diet. Participants included 236 feeding-clinic children in three diagnostic groups: 50 with autism, 84 with other special needs, and 102 without special needs. Children's weight was measured as body mass index percentile (BMI%), with only 26.4% of the present sample found to be underweight (BMI% less than 10). Parents reported children's diet variety as the number of 139 common foods accepted, children's FUSSINESS with the Child Eating Behavior Questionnaire, and their own use of four actions from the Parent Mealtime Action Scale: POSITIVE PERSUASION, INSISTENCE ON EATING, SNACK MODELING, SPECIAL MEALS. Multiple regression found that only SPECIAL MEALS explained variance in children's BMI% and diet variety. For children without special needs, mediation analysis revealed that variance in children's BMI% explained by FUSSINESS was accounted for entirely by the parent's preparation of SPECIAL MEALS. For all diagnostic groups, mediation analyses revealed that variance in children's diet variety explained by FUSSINESS was accounted for by the parent's use of SPECIAL MEALS. We conclude that although the parent's use of SPECIAL MEALS may improve BMI% in fussy-eating clinic children, it may also perpetuate their limited diet variety.

The Parent Mealtime Action Scale (PMAS). Development and association with children's diet and weight.

A new and comprehensive Parent Mealtime Action Scale (PMAS) was developed to identify dimensions of mealtime behaviors used by parents, then examined for its usefulness to explain variance in children's diet and weight status. Exploratory factor analysis with 2008 mothers and two confirmatory factor analyses with 541 mothers and 439 fathers produced a 31-item scale with nine dimensions. Mothers reported more gentle PMAS actions like setting SNACK LIMITS, ensuring DAILY FV AVAILABILITY, and using FAT REDUCTION and POSITIVE PERSUASION during meals, whereas fathers reported more forceful PMAS actions like INSISTENCE ON EATING. Seven PMAS dimensions explained variance in children's diet and weight status even when in competition with three well-known predictors (genetic risk, exercise, television). Children with healthier diets and weight had parents who often ensured DAILY FV AVAILABILITY and used FAT REDUCTION, POSITIVE PERSUASION, and INSISTENCE ON EATING during meals, but who rarely showed SNACK MODELING, allowed children too MANY FOOD CHOICES, or made them SPECIAL MEALS different from the shared family meal. Parents also may respond to children's overweight by using more FAT REDUCTION. The PMAS offers a new research, clinical, and educational tool to guide parents in actions most associated with children's diet and weight status.

The Glucose Control Resistance Scale

Objective: While past research found family conflict, disordered eating, body image concerns and anxious self-doubts may affect adolescent diabetic glucose control, available measures of adherence mainly focus on management tasks. The current study aimed to combine measures of emotional distress and beliefs with decisions concerning management in a new measure of resistance to treatment adherence: the 12-item Glucose Control Resistance Scale (GCRS). Methods: Participants included 135 adolescents and their parents from a pediatric diabetes clinic. Family conflict, body image concerns, anxious self-doubts and glucose control resistance were assessed. Results: Factor analysis identified 12 items, with loadings of ≥0.40, which were used to form the GCRS. The scale had adequate reliability and there was a significant correlation between child and parent GCRS scores. One factor, family conflict, was significantly related to hemoglobin A1c (HbA1c) levels, but a set of four factors explained a total of 12% of the variance in HbA1c levels. Of the demographic variables considered (gender, number of parents at home, age, body mass index z-score), only gender was significantly associated with adolescent perceptions of family conflict. Conclusion: The GCRS may allow diabetic care teams to better understand the origin of family conflict perceptions and the motivational beliefs that modify behavior and contribute to independent self-management and glucose control. Each question was designed to be meaningful in interventions by addressing common items of resistance to adherence and impulsive management decisions. The GCRS may be used by providers as an initial short screening survey on an annual or semi-annual basis.

Teaching chewing: a structured approach.

OBJECTIVE: A structured intervention was used to teach chewing to two children with special needs. Neither child had a history of chewing or eating high-textured food. METHOD: The intervention combined oral-motor and behavior components to teach chewing. A multiple baseline design was used to evaluate treatment effectiveness. RESULTS: Both children improved their chewing skills while increasing the texture of foods eaten and the variety of foods eaten. CONCLUSION: This structured intervention could be used to teach chewing to a range of children who did not acquire this skill during normal development.

Reducing tube feeds and tongue thrust: combining an oral-motor and behavioral approach to feeding.

OBJECTIVE: A treatment package combining oral-motor and behavioral interventions was implemented for a 6-year-old girl with Down syndrome referred to an intensive day treatment feeding program for gastrostomy tube dependence and food refusal. The participant exhibited a tongue thrust, resulting in the expulsion of all foods presented. METHOD: An oral-motor procedure was used to reduce the tongue thrust and allow the food to be swallowed. This procedure was paired with positive reinforcement and escape prevention to increase oral consumption of liquids and solids. A multiple-probe design was used to evaluate treatment effectiveness. RESULTS: By the end of treatment, tube feedings were eliminated and tongue thrust was significantly reduced. CONCLUSION: This intervention demonstrated the successful combination of oral-motor and behavioral components in the treatment of a severe feeding problem. It could serve as a model for the development of future interventions.

Variables associated with the use of complete oral calorie supplements in children with feeding problems.

OBJECTIVE: To examine child and parent variables associated with complete oral calorie supplement use among children with feeding problems. DESIGN: Correlational examination of data from patient intake surveys. SETTING: Hospital-based feeding program. PARTICIPANTS: Participants included 281 parents of children referred to a hospital-based feeding clinic, including 114 who received supplements (70.2% boys; mean age, 60.1 months) and 167 who did not receive (79.6% boys; mean age, 67.5 months). VARIABLES MEASURED: Children's age, gender, weight status, diagnostic category (no special needs, autism, or other special needs), supplement intake, oral motor problems, child mealtime behavior (using the Child Eating Behavior Questionnaire), parent feeding practices (using the Parent Mealtime Action Scale), and diet variety for child and parent. ANALYSIS: Chi-square analyses compared children who did and did not receive supplements for their percentage of gender, diagnostic, and weight status categories; t tests or Mann-Whitney U tests compared children who did and did not receive supplements, for age, oral motor problems, children's mealtime behavior, parent feeding practices, and diet variety. RESULTS: Compared with children who did not receive nutritional supplements, those who did were younger (P < .01) and more underweight (P < .001), and showed less Food Responsiveness (P < .001), less Food Enjoyment (P < .001), more Food Satiety (P < .001, and more Slow Eating (P < .001), and their parents were more likely to use Insistence on Eating (P < .001). CONCLUSIONS: Whereas supplement use was related to underweight, 78.2% of children receiving them were normal weight or overweight, which suggests that supplements are being used to address mealtime selective eating. The use of supplements should be considered carefully because they do not appear to increase diet variety and may increase the chance of overweight over time.

Food refusal in children: a review of the literature.

Food refusal is a severe feeding problem in which children refuse to eat all or most foods presented and exhibit problems with growth. This review discusses the definition, etiology, and interventions pertaining to food refusal. The interventions utilized for food refusal typically consist of several treatment components. These treatment components are reviewed and implications for future interventions are discussed.

Practice does make perfect. A longitudinal look at repeated taste exposure.

Previous research has found that 10-15 exposures to a novel food found can increase liking and consumption. This research has been, however, largely limited cross-sectional studies in which participants are offered only one or a few novel foods. The goal of the current study uses a small clinical sample to demonstrate the number of exposures required for consumption of novel foods decreases as a greater number of foods are added to the diet. Evidence that fewer exposures are needed over time may make interventions based upon repeated exposure more acceptable to parents and clinicians.

Combining repeated taste exposure and escape prevention: an intervention for the treatment of extreme food selectivity.

Repeated taste exposure has been used to introduce novel foods in several settings, but none of these efforts have targeted clinical populations. This study describes an intervention that combines repeated taste exposure and escape prevention in the treatment of extreme food selectivity in two children with autism. Future applications of repeated taste exposure are discussed.

Overweight and average-weight children equally responsive to "Kids Choice Program" to increase fruit and vegetable consumption.

Secondary analyses were conducted for children participating in the school-based Kids Choice Program [Hendy, H. M., Williams, K., & Camise, T. (2005). "Kids Choice" school lunch program increases children's fruit and vegetable acceptance. Appetite, 45, 250-263.] to examine whether fruit and vegetable consumption and preference ratings by overweight and average-weight children within the original sample were equally responsive to the program. The Kids Choice Program produced increased fruit and vegetable consumption by both overweight and average-weight children that lasted throughout the month-long program, while avoiding "over-justification" drops in later fruit and vegetable preference ratings. We believe that the Kids Choice Program shows promise for encouraging overweight children to improve nutrition and weight management behaviors while in their everyday peer environment.

"Kids Choice" school lunch program increases children's fruit and vegetable acceptance.

The "Kids Choice" school lunch program used token reinforcement, food choice, and peer participation to increase children's fruit and vegetable consumption without later drops in food preference sometimes found in past research and often called 'overjustification effects.' Participants included 188 school children (92 boys, 96 girls; mean age = 8.0; 95% Caucasian). After four baseline meals, children were randomly assigned for 12 meals to receive token reinforcement for eating either fruits or vegetables. Observers recorded fruit and vegetable consumption and provided token reinforcement by punching holes into nametags each day children ate their assigned foods, then once a week children could trade these tokens for small prizes. Fruit and vegetable preference ratings were gathered with child interviews during baseline, and during follow-up conditions two weeks and seven months after the token reinforcement program. Consumption increased for fruit and for vegetables and the increases lasted throughout reinforcement conditions. Two weeks after the program, preference ratings showed increases for fruit and for vegetables. Seven months later, fruit and vegetable preferences had returned to baseline levels, suggesting the need for an ongoing school lunch program to keep preferences high, but also showing no signs of "overjustification effects" from the token reinforcement used in the "Kids Choice" school lunch program.